U5233

For PPS claims, and claims with provider numbers beginning with '210', the admission date falls within a risk GHO paid period, but no GHO paid code or condition code '69', is indicated on the claim.

*** OR ***

For Non-PPS inpatient and SNF claims, the statement dates fall within, or overlap a Risk GHO period, but no GHO paid code or condition code ‘69’ is indicated on the claim.

Always remember to check beneficiary eligibility prior to submitting the claims to your fiscal intermediary. There are two ways to obtain this information:

Code indicates a request for a supplemental payment for IME/DGME/N&AH (Indirect Medical Education/Graduate Medical Education/Nursing and Allied Health)

38067

This inpatient claim (11x, 18x, 21x or 28x) contains dates of service that overlap a previously processed outpatient claim (12x, 13x, 14x, 22x, 23x, 71x, 83x or 85x).

Verify the status of your claims before refiling. There are several ways to verify this information.

If the beneficiary is in an inpatient setting, example: skilled nursing facility, and has to have an outpatient service in another facility it is appropriate to apply the occurrence span code 74 and the dates the patient is out of the inpatient setting.

C7010

The edited inpatient or outpatient claim has from/thru dates that overlap a hospice election period and is not indicated as treatment of a non-terminal condition (condition code '07').

A Medicare Coordinated Care Demonstration (MCCD) notice of election (89a) from date overlaps a hospice election period

Always remember to check beneficiary eligibility prior to submitting the claims to your fiscal intermediary. There are three ways to obtain this information:

38200

This claim is an exact duplicate of a previously submitted claim where the following fields on the history and processing claim are the same:

***

For ambulance claims, this reason code will be bypassed if one claim has value code 32 and the other claim does not.

***

For outpatient claims, this reason code is bypassed if either the history or incoming claim contained condition code GO.

Verify the status of your claims before refiling. There are several ways to verify this information.

38108

Standard narrative: this outpatient claim (13X or 85X), contains dates of service that overlap a previously processed inpatient claim (11X only), but at least one revenue code is the same on both claims, and the provider numbers are equal. The reason code will be bypassed in the following situations:

1) a span code 74 is present on the outpatient claim and the inpatient service dates are within or equal to the span code 74 days;

2) revenue code 29X, 54X, 960, 961 or 969 is on the claim.

Verify the status of your claims before refiling. There are several ways to verify this information.

If the beneficiary is in an inpatient setting, example: skilled nursing facility, and has to have an outpatient service in another facility it is appropriate to apply the occurrence span code 74 and the dates the patient is out of the inpatient setting.

39933

This reason code will be assigned when all detail lines on an outpatient claim fall within a home health PPS episode. Contact the regional home health intermediary (RHHI) for assistance should assistance be required.

Verify the beneficiary eligibility prior to submitting the claims to your fiscal intermediary. There are three ways to obtain this information:

T5052

The Health Care Financing Administration records indicate the beneficiary is not in file. Please verify the beneficiary's identification and submit a new claim.

Verify the beneficiary eligibility prior to submitting the claims to your fiscal intermediary. There are three ways to obtain this information:

10417

This is a claim level reject reason code for claims that have all line items rejected by V8022, V8024, U5412 or U5413 from common working file (CWF).

The individual reason codes listed for 10417 describe the following:

39929

This claim has rejected due to all line items have rejected and/or rejected and denied. Review each line item to identify the applicable line edit, and utilize the reason code narratives to identify possible billing error(s). If the primary procedure line is not payable due to an edit assigned, then all incidental lines on the same date of service will not be payable due to other related edits.

******************************************************

If an adjustment needs to be submitted to correct billing error(s) on a rejected line item, then each applicable line item will need to be deleted and re-keyed in its entirety in order for the previous edit to be deleted.

Also, remember incidental lines will need to be deleted and re-keyed.

There are several ways you can review the claim and see the line item reason code:

36428

The intermediary has received a claim for mammography screening, however, the provider's certification date is greater than the from date on the claim or the provider is not certified as a screening mammography supplier.

Change request (CR) 4303 – Mammography Facility Certification File – Updated Procedures and Content – provides guidelines for carriers/intermediaries to download the most recent Mammography Quality Standards Act (MQSA) file on a weekly basis and use it to adjudicate claims.

The MQSA ensures that all facilities that provide mammography services meet national quality standards.

The FDA Center for Devices and Radiological Health is responsible for collecting certificate fees and surveying mammography facilities (screening and diagnostic). The FDA provides CMS with a file that contains a listing of all facilities that have been issued certificates to perform mammography services.

Joint Signature Memorandum/Technical Direction Letter (JSM/TDL)-08161, dated 01-29-08, recommends that providers hold the mammography claims for seven (7)-business days to allow for any changes in certification data to be uploaded accordingly. After the seven (7)-business day hold, providers may submit their claims for payment. This may help lower the receipt of this reason code.

This information can also be found in the CMS Internet Only Manual (IOM), Publication 100-04, Chapter 18, and Section 20.1.

http://www.cms.hhs.gov/manuals/downloads/clm104c18.pdf

31715

Beginning with dates of service on and after 01/01/07; it has been determined the units of service are in excess of the medically reasonable daily allowable frequency. The excess charges due to units of service greater then the maximum allowable may not be billed to the beneficiary and; this provision can neither be waived nor subject to an advanced beneficiary notification (ABN).

The Centers for Medicare & Medicaid Services (CMS) established units of service edits referred to as Medically Unlikely Edits (MUEs) to lower the Medicare fee-for-service paid claims error rate. This reason code is hitting against those edits.

To become familiar with the MUEs and the process, you should visit change request 5402 and/or MLN Matters article MM5402. The link is below.

CR5402 - http://www.cms.hhs.gov/transmittals/downloads/R178PI.pdf

MM5402 - http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5402.pdf

CMS has also released article concerning the MUEs, as well as a few of the codes. You can find the information at the link below.

http://www.cms.hhs.gov/NationalCorrectCodInitEd/08_MUE.asp

Verify the information submitted on the claims, correct the error and resubmit the claim.

38038

For dates of service on or after 07/31/00, whether any rev code lines are equal or not, outpatient OPPS types of bills (12X, 13X, 14X, 76X, 75X, 34X or any bill containing condition code 07) cannot have overlapping dates when the provider numbers are equal unless condition code 'G0' or '20' or '21' is present on the claim. All OPPS services must be reported on the same bill.

Verify the status of your claims before refiling. There are several ways to verify this information.

Condition code G0: Distinct Medical Visit – Report this code when multiple medical visits occurred on the same day in the same revenue center. The visits were distinct and constituted independent visits.

Condition code 20: Beneficiary Requested Billing – Provider realizes services are non-covered level of care or excluded, but beneficiary requests determination by payer. (Currently limited to home health and inpatient SNF claims).

Condition code 21: Billing for Denial Notice – Provider realizes services are non-covered level of care or excluded, but requests notice from Medicare or other payer.

38119

Your SNF claim is being returned because of a possible out of sequence billing issue.

SNF claims have to be submitted monthly and in sequential order. When you submit a claim it has to finalize before you can submit the next claim.

32402

A HCPCS code reported on this claim is not valid for a revenue code reported.

Or HCPCS code is not valid for the date on which the services were provided.

Covered charges for the line item being edited are greater than zero.

HCPCS table file contains at least one revenue code for the HCPCS being edited.

Note: if no revenue codes are present on the HCPCS table, then all revenue codes are assumed to be allowable for the HCPCS.

Note: for an 18x TOB with a “Y” in the PPS indicator (hospital swing-bed PPS SNF claims), the HCPC file must have 0022 as an allowable revenue code and the 0022 covered charges must not be greater than zero.

If the revenue code on the line item being edited does not match one of the allowable revenue codes for the HCPC, the error is assigned.

Verify the information submitted on your claim. You can verify the revenue to HCPCS code in direct data entry (DDE).

Choose option -1 (inquiries), and option -13 (revenue codes) or option -14 (HCPCS). The screens will give information pertaining to the allowable codes for the revenue lines.

Correct the claim and resubmit.

19301

If the operating physician is required or if an operating UPIN is present, the physician's last name and first name must be present. If any name is present, the UPIN must be present. Or 'NPP' is an invalid UPIN.

Check your claims for this information, and if it is missing, make sure you add the missing information. The claim can be updated and resubmitted.

38117

The type of bill is equal to an SNF or the claim is a non-PPS inpatient claim. The admission date is on or after 4-1-95. The statement covers from date indicated is after the admission date. There is a prior claim pending. The prior claim's through date is one day before this claim's from date. In order to process in sequence, the prior claim needs to finalize first.

This error is an out-of-sequence error. To process a SNF claim, a provider has to wait for the previous month’s claim to finalize, before submitting the next month’s claim.

The order the claims should be submitted are inpatient, outpatient, and then SNF.

32206

The revenue code is invalid for this type of bill.

Verify the information submitted on your claim. You can verify the revenue code in direct data entry (DDE).

Choose option -1 (inquiries), and option -13 (revenue codes). Key in the revenue code you have and press enter. The revenue code table inquiry screen shows the following information:

When reviewing the data on this screen, if there is a “Y” in the fields, this tells you the revenue code is allowed for the TOB and if a “Y” is in the field with a date you can submit the code on the claim. If there is an “N,” you cannot submit the code on the claim.

If you do not use DDE, you can review the CMS, internet only manual (IOM), publication 100-04, chapter 25 – Completing and processing the form CMS-1450 data set (see link below).

http://www.cms.hhs.gov/manuals/downloads/clm104c25.pdf

Correct the claim and resubmit.

12206

The sum of covered days (UB92 field 7) and noncovered days (UB92 field 8) is not equal to the days as calculated between the statement covers from date and the statement covers through date (UB92 field 6).

Verify the number dates of service in the “from and thru” date fields and code the covered days and non-covered days appropriately.

Correct the claim and resubmit.

77777

This claim transaction has missing or invalid information that will not allow it to adjudicate. This claim transaction has been previously returned to the provider (RTP) more than two times for the same reason code with comments in the remarks section from the FI and resubmitted without corrections. Please review the FI's comments in the remarks section and make the appropriate corrections prior to resubmitting. If you have questions on the FI's comments, please contact customer service at 1-877-602-8816.

This reason code is received when the claims department continues to give you feedback on your RTP claim.

Once you receive this reason code, you need to submit the claim as a new claim with the correct coding guidelines.

38037

This outpatient claim is a duplicate to a previously submitted outpatient claim.

One of the following conditions exist on both claims:

Verify the status of your claims before refiling. There are several ways to verify this information.